PURPOSE: COPD afflicts 24 million people and is the fourth leading cause of death in the United States. For this patient population, overuse and misallocation of respiratory care services is a common finding. In fact, nebulized bronchodilator therapy is commonly prescribed in excess to hospitalized patients despite the equivalent efficacy of metered dose inhalers with valved holding chambers. The objective of this study was to evaluate the current practice in the management of severe, non-life threatening COPD exacerbations and determine the number of missed nebulized respiratory treatments.
METHODS: This study was a retrospective chart review of all patients admitted from January 2007 to June 2008 at two academic medical centers with a primary diagnosis of severe, non-life threatening COPD exacerbation (ICD 9 code 491.21). Each patient's COPD treatment regimen was evaluated and the potential for nebulization to metered-dose inhaler (MDI) with valved holding chamber (VHC) conversion was assessed. The number of missed nebulized respiratory treatments was also identified.
RESULTS: Two hundred fifty-nine patients met inclusion criteria. Two hundred thirty-five (90.7%) patients received nebulized bronchodilators in the treatment of COPD exacerbations; 81.1% of these patients could have potentially utilized MDI with VHC. During this time, 11,422 nebulized medication doses were scheduled; however, 2,775 (24.3%) were omitted. Patients missed 23% and 26% of scheduled, nebulized albuterol and ipratropium doses, respectively. Even the long acting beta-agonist arformoterol was omitted 21.3% of the time.
CONCLUSION: The management of non-life threatening COPD exacerbations in hospitalized patients needs significant improvement. The number of missed doses of inhaled therapies is unacceptable and could potentially be reduced by more patients receiving respiratory treatments administered via MDI-VHC.
CLINICAL IMPLICATIONS: Conversion to MDI-VHC could have significant impact on patient outcomes, length of stay, and medication cost. The development of a respiratory therapist driven conversion protocol should be implemented.
DISCLOSURE: Andrew Woods, No Financial Disclosure Information; No Product/Research Disclosure Information